FLUOROSCOPY

https://www.youtube.com/watch?v=3UG9T1OQxEA
https://www.youtube.com/watch?v=eDicWq91JF4
https://www.youtube.com/watch?v=0zM5QboicLo
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Learning Objectives
By the end of this Lecture the student will be able to:

 Differentiate between fluoroscopic and radiographic examinations

 List the basic components of the fluoroscopic system and identify
the function of each component
 Describe a typical basic fluoroscopic image Intensifier
 Describe advantages of image intensified fluoroscopy over
conventional screen fluoroscopy
 Identify uses of dynamic and static fluoroscopic recording systems
 Discus digital fluoroscopic image acquisition
 Differentiate between conventional fluoroscopy, image intensifier
fluoroscopy, and digital fluoroscopy
References
• Bushberg, The Essentials of Physics and Medical
Imaging, Williams & Wilkins Publisher.
• Positioning in Radiography: By k.C.Clarke.
• Text book of radiographic positioning and related
anatomy;bykenneth L.Bontrager,5th edition

Websites
• http://www.e-radiography.net/
FLUOROSCOPY
History
▪ Invented by Thomas A. Edison in 1896
▪ Conventional film radiography is restricted to static
patient exams. If dynamic events need to e studied such
as movement contrast materials through gastrointestinal
tract (GIT) the image must be viewed directly using a
dynamic method.
Purpose:
 To perform dynamic studies.
 Visualize anatomical structures in real time or motion.
 View the motion and function of anatomic organs.
Fluoroscopic systems
Conventional fluoroscopic systems
 Earliest fluoroscopic systems used phosphor screens where the
transmitted x-ray caused scintillations that were viewed
directly.
Fluoroscopic systems

Direct Fluoroscopy

In older fluoroscopic examinations radiologist stands behind screen and

view the image.
Fluoroscopic systems
Conventional fluoroscopic systems
The images of this type were of
very poor quality for a number
of reasons:-
- Poor light output by the
fluorescent screen
- Low efficiency of the light
conversion
mechanism
- Poor spatial resolution
for that fluorescent screens are no
longer used since they gave high
radiation dose to the operator.
Fluoroscopic with image intensifiers

What is an Image Intensifier ?

A complex electronic imaging device that receives the
remnant beam and converts it to light and increases the
intensity of the light.
The image intensifier tube is contained in a glass envelope
in a vacuum and mounted in a metallic container which
provides protection for the components.
Fluoroscopic with image intensifiers
Fluoroscopic with image intensifiers

Image Intensifier Schematics

Input Phosphor

 Constructed of cesium
iodide.
 Responsible for
converting the incident
photon’s energy to a
burst of visible light
photon.
◦ Similar to intensifying
screens in cassettes.
 Standard size varies
from 10 - 35 cm.
◦ Normally used to
identify the II tubes.
Photocathode
 Thin metal layer bonded
directly to the input phosphor.
 Usually made of Cesium and
Antimony compounds that
respond to light stimulation.
 Responsible for
Photoemission.
 Electron emission after light
stimulation
 The number of electrons
emitted is directly proportional
to the intensity of light
intensity of the incident x-ray
photon.
Electrostatic Focusing Lenses
 A series of lenses inside the II
tube to maintain proper focus
of the photoelectrons emitted
from the photocathode.
 They contain a positive charge.
 They are located along the
length of the II tube.
 The focusing lenses assist in
maintaining the kinetic energy
of the photoelectrons to the
output phosphor.
Output Phosphor
 Usually constructed of zinc cadmium sulfide crystals. Serves
to increase illumination of the images by converting
photoelectrons to light photons.
Spot Film Device
▪ Used to make permanent
images during the
radiographic examination.
▪ Film is positioned b/w the
patient and the image
intensifier.
▪ When the film is needed,
the radiologist actuates the
control that brings the
cassette in position. This
changes the tube from
fluoroscopic mA to
radiographic mA.
▪ During fluoroscopy, the
tube is operated at less
than 5 mA.
TV MONITORS
 This practical and efficient viewing system was employed
because of the limitations of the mirror optic viewing
system.
TV monitors:
1. Enables viewing by multiple persons.
2. Monitors may be located in remote locations other than the
radiographic room.
3. Image brightness and contrast can be manipulated.
4. Images may be stored on different medium for reviewing
at a later time.
Fluoroscopy -Modes of operation

 Manual Mode
◦ Allow the use to select the exact MA and KVp required
 AEC Mode
◦ Allow the unit to drive the KVp and MA to optimize
dose and image quality
 Pulsed Digital mode
◦ Modifies the fluoroscopic output by cutting by cutting
out exposure between pulses
◦ With the pulsed mode, it can be set to produce less than
the conventional 25 or 30 images per second. This
reduces the exposure rate.
Fluoroscopy Units

❑ Smaller facilities may use one fluoroscopic system for

a wide variety of procedures
❑ Larger facilities have several units dedicated to specific
applications, such as:

▪ Gastrointestinal units
▪ Remote fluoroscopy rooms
▪ Peripheral angiography units
▪ Cardiology catheterization units
▪ Biplane angiography units
▪ Mobile fluoroscopy – C arms units
 Fluoroscopy Units
1/An over table model
Where the x-ray tube is placed above the table top, and the
image intensifier under the table surface.
Fluoroscopy Units
2/An under table model
Where the x-ray tube is placed under the table surface , and the
image intensifier over the table top.
Fluoroscopy Units

An under table model

Fluoroscopy Units

The table have the ability to tilt from horizontal to vertical

 Fluoroscopy Units
3/Single or bi-planar cine –fluoroscopy model

▪ Where the x-ray tube and

image intensifier are fixed
to c-arms.
▪ Mostly used in surgical
theatres.
Fluoroscopy Units
 Remote control systems
Digital Fluoroscopy
❑Digital fluoroscopy is currently most commonly configured as a
conventional fluoroscopy system
❑This method uses digital detector technologies (eg, flat-panel
"direct" detection of x rays and charge- coupled device technology)
❑The analog video signal is converted to a digital
format with an analog-to-digital converter (ADC).
Radiation Protection
General Rule

(ALARA Principle)
As
Low
As
Reasonably
Achievable

766894
Radiation Protection

more exposure

Time

Longer usage
 Radiation Protection

TIME
 Take foot off fluoro pedal if physician is not viewing the TV monitor
 Use last image hold (freeze frame)
 Five-minute timer
 Use pulsed fluoro instead of continuous fluoro
 Pulsed Low-Dose provides further reduction with respect to Normal
Dose continuous mode:
 Use record mode only when a permanent record is required
 Record beam-on time for review
Radiation Protection

Distance is large factor for reducing

exposure.
Inverse Square law
Distanc e “ When you double the distance the
exposure rate is decreased by 4 times ”
 Radiation Protection
DISTANCE
- One step back from tableside:
cuts exposure by factor of 4

- Move Image Int. close to patient:

less patient skin exposure less
scatter
- Source to Skin Distance (SSD):

38 cm for stationary fluoroscopes

30 cm for mobile fluoroscopes
Radiation Protection

X-ray Tube Position  Position the X-ray tube under the

patient not above the patient.
 The largest amount of scatter
radiation is produced where the
x-ray beam enters the patient.
 By positioning the x-ray tube
below the patient, you decrease
the amount of scatter radiation
that reaches your upper body.
Radiation Protection
Shielding
Increasing the amount of shielding around a source of
radiation will decrease the amount of radiation exposure.

To avoid scatter Be sure to shield all directions.

+ -

Shielding
Radiation Protection
 SHIELDING
- Lead aprons: cut exposure by factor of 20
- Proper storage (hanging vs. folding)
 Radiation Protection

Protection tools

Eye goggles curtain thyroid shield Lead Apron

38
Radiation Protection
Collimation
Collimate tightly to the area of interest.
➢ Reduces the patient’s total entrance skin exposure.
➢ Improves image contrast.
➢ Scatter radiation to the operator will also decrease.
Radiation Protection
Safety in Fluoroscopy
• Familiarity with specific fluoro units
Factors influencing dose:
▪patient size
▪ kVp, mA and time
▪tube - patient distance (SSD)
▪Image Intensifier - patient distance
▪image magnification vs. patient dose
▪ x-ray field collimation
▪oblique's vs. perpendicular views
Radiation Protection
Safety in Fluoroscopy
▪ Standard Operating Procedures
- each clinical protocol / procedure
- modes of operation, image recording
- emphasis on minimizing duration
- risk / benefit on a case-by-case basis

▪ Equipment quality control

- periodic PMs
- prompt calibrations
- post radiation output values
- check aprons, shields, gloves annually
Radiation Protection
Final Summary Golden rules”
 Keep the II close to the patient
 Do not overuse magnification modes
 Keep the x-ray tube at maximal distance from patient
 Use higher kVp where possible
 Wear protective aprons and radiation monitors, and know where
scatter is highest
 Keep your distance, as far as is practicable
Homework
 Fluoroscopy image quality (FOV, Frame rate, Automatic
brightness control (ABC))
 Noise (Digital subtraction angiography (DSA))
 Patient dose reduction
 Kerma area product (KAP)
 Interventional reference point
 Fluoroscopy vs Radiography?